Granulosa-Theca Cell Tumors Follow-up

  • Author: Chad M Michener, MD; Chief Editor: Warner K Huh, MD   more...
 
Updated: Jan 4, 2010
 

Further Outpatient Care

  • Follow-up should occur at 2- to 3-month intervals for the first 2 years for patients not undergoing chemotherapy. Then, this can be spaced out to every 4-6 months for the next 3 years, then yearly thereafter.
    • A history should be obtained and pelvic examination should be performed at each visit. Also, serum determination of tumor markers (ie, inhibin levels) should be performed if these were elevated preoperatively or immediately postoperatively.
    • If any evidence of recurrence arises during follow-up, imaging studies, usually an abdominopelvic CT scan should be performed to look for recurrent tumors. Most recurrences are confined to the abdomen and pelvis. Other imaging studies may be ordered as dictated by physical examination findings.
  • Long-term follow-up is required in all patients with GCTs because at least 50% of recurrences are found more than 5 years after initial treatment.
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Inpatient & Outpatient Medications

  • Antiemetics
    • Ondansetron, granisetron, metoclopramide, and prochlorperazine can be used to treat or prevent emesis in an inpatient or outpatient setting. Note that some chemotherapeutic agents (eg, cisplatin, cyclophosphamide) cause a delayed emesis (>24 h after chemotherapy).
    • The adult dose of metoclopramide is 30-40 mg PO bid or 10 mg qid for 3 days. The pediatric dose is 10-20 mg PO bid for 3 days.
    • The adult dose of prochlorperazine is 5-10 mg PO q6-8h or 25 mg PR bid. The pediatric dose is 0.1-0.15 mg/kg PO q6-8h or 0.2-0.3 mg/kg PR bid.
    • Both of these drugs may cause sedation and dystonic reactions.
  • Hematopoietic growth factors
    • A host of growth factors now can be given in place of antibiotics and transfusion of blood products to treat severe chemotherapy-induced or radiation-induced bone marrow suppression.
    • Available agents include granulocyte colony-stimulating factor (neutrophil-specific), granulocyte-macrophage colony-stimulating factor (neutrophil-, eosinophil-, and monocyte-specific), and erythropoietin (red cell–specific). Indications for each are patient-dependent.
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Transfer

Patients admitted with nonspecific complaints who are found later to have a pelvic mass and/or other signs of malignancy (ie, ascites, elevated tumor marker levels, outward signs of abnormal sex hormone production) should be transferred for operative and postoperative management by a trained gynecologic oncologist if one is not available at the current facility. Otherwise, consultation generally can be performed on an outpatient basis, preferably preoperatively in women with pelvic masses.

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Deterrence/Prevention

No means of preventing sex cord–stromal tumors of the ovary are known.

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Complications

  • In 10-15% of cases, acute abdominal symptoms may be the presenting complaints for patients with rupture of their mass, hemorrhage into the mass, or torsion of the ovary.
  • Adverse effects from chemotherapy can be expected but generally are well tolerated. Specific adverse effects vary with the type of chemotherapy given and have been discussed in In/Out Patient Meds and Medication.
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Prognosis

  • Prognosis for granulosa-theca cell tumors generally is very favorable. GCTs are considered to be tumors of low malignant potential. Approximately 90% of GCTs are at stage I at the time of diagnosis (see Staging). The 10-year survival rate for stage I tumors in adults is 90-96%. GCTs of more advanced stages are associated with 5- and 10-year survival rates of 33-44%. The overall 5-year survival rates for patients with AGCTs or JGCTs are 90% and 95-97%, respectively. The 10-year survival rate for AGCTs is approximately 76%. In contrast, the overall 5-year survival rate for patients with epithelial ovarian cancer is only 30-50% because only one quarter of patients present with stage I disease.
  • Recurrences in patients with AGCTs tend to be later than in patients with JGCTs. In a recent study, Mom et al reported a recurrence rate of 43% in 30 patients with stage I-III GCT observed over 10 years. Mom states that while the recurrence rate might be high, it falls within the range of 9-39% cited in other studies.[28] Average recurrence for the adult type is approximately 5 years after treatment, with more than half of these occurring more than 5 years after primary treatment. These tumors tend to follow an indolent course, with a mean survival of 5 years after the recurrence is diagnosed. The 10-year overall survival after an AGCT recurrence is in the 50-60% range.
  • JGCTs recur much sooner, with more than 90% of recurrences occurring in the first 2 years. Recurrence in these patients is rapidly fatal.
  • Tumor stage at the time of initial surgery is the most important prognostic variable. Besides stage, Zhang et al found early stage disease and age younger than 50 years to be statistically significant factors in predicting survival. Other features associated with a poorer prognosis include high mitotic rates, moderate-to-severe atypia, preoperative spontaneous rupture of the capsule, and tumors larger than 15 cm. The presence of bizarre nuclei and tumor rupture intraoperatively does not appear to affect prognosis.
  • Approximately 10% of tumors occur during pregnancy, but this does not affect prognosis. Perform surgical treatment for an adnexal mass in pregnancy early in the second trimester in order to minimize surgical and pregnancy risks.
  • True thecomas have an excellent prognosis, with 5-year survival rates of nearly 100%. However, their estrogen-producing capabilities may cause increased overall morbidity due to endometrial hyperplasia, endometrial adenocarcinoma, and possibly, breast carcinoma.
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Patient Education

  • Patients must be educated about the need for long-term follow-up, especially those with AGCTs. Early diagnosis and treatment can lead to prolonged survival in this group of patients.
  • For excellent patient education resources, see eMedicine's Women's Health Center and Cancer and Tumors Center. Also, see eMedicine's patient education article Ovarian Cancer.
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Contributor Information and Disclosures
Author

Chad M Michener, MD  Assistant Professor, Obstetrics/ Gynecology and Women's Health Institute, Section of Gynecologic Oncology, The Cleveland Clinic

Chad M Michener, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists and Society of Gynecologist Oncologists

Disclosure: Nothing to disclose.

Coauthor(s)

David C Starks, MD  Fellow, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Cleveland Clinic Foundation

Disclosure: Nothing to disclose.

Specialty Editor Board

Bruce A Meyer, MD, MBA  Executive Vice President for Health System Affairs, Chief Clinical Officer, Interim CEO, University Hospitals; Professor, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical School

Bruce A Meyer, MD, MBA is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Physician Executives, American Institute of Ultrasound in Medicine, Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, Medical Group Management Association, and Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Frederick B Gaupp, MD  Consulting Staff, Department of Family Practice, Hancock Medical Center

Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Chief Editor

Warner K Huh, MD  Professor, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Senior Scientist, Comprehensive Cancer Center, University of Alabama School of Medicine

Warner K Huh, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Surgeons, American Society of Clinical Oncology, Massachusetts Medical Society, and Society of Gynecologist Oncologists

Disclosure: MERCK Consulting fee Consulting; GSK Consulting fee Consulting; ROCHE PHARMA/DIAGNOSTICS Consulting fee Consulting; HOLOGICS Consulting fee Consulting; HELIX BIOPHARMA Consulting fee Consulting; COVIDIEN Consulting fee Consulting; INTUITIVE SURGICAL Surgical Proctor

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Microfollicular pattern of an adult granulosa cell tumor at 100X magnification. Inset is characteristic Call-Exner bodies and nuclear grooves (400X). Image courtesy of James B. Farnum, MD, TriHealth Department of Pathology.
Less well-differentiated diffuse pattern of adult granulosa cell tumor. Monotonous pattern can be confused with low-grade stromal sarcoma (200X). Inset is high-power magnification demonstrating nuclear grooves and nuclear atypia. Image courtesy of James B. Farnum, MD, TriHealth Department of Pathology.
Juvenile granulosa cell tumor. Multiple follicles in various shapes and sizes (200X). Inset shows nuclei that are rounded, hyperchromatic, lacking grooves and showing atypia, and are abnormal mitotic figures (400X). Image courtesy of James B. Farnum, MD, TriHealth Department of Pathology.
Gyriform pattern of adult granulosa cell tumor. Undulating single-file rows of granulosa cells (200X). Image courtesy of James B. Farnum, MD, TriHealth Department of Pathology.
Theca cell tumor. Typical thecoma with lipid-rich cytoplasm, pale nuclei, and intervening hyaline bands (200X). Image courtesy of James B. Farnum, MD, TriHealth Department of Pathology.
Luteinized thecoma. Vacuolated theca cells with an abundant fibromatous stroma (200X). Image courtesy of James B. Farnum, MD, TriHealth Department of Pathology.
 
 
 
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